Now that you have a framework for ethical decision making, it’s time for personal reflection. Post your own value statement that identifies 3-5 of your personal values that you use to make decisions.
Consider whether your personal values apply in all situations. If you value honesty above all else, would you lie in certain circumstances, such as to save the life of another? Identify whether there are circumstances for each of your values that you would behave in conflict with those values.
CHAPTER 1
Theory of Healthcare Ethics
Jim Summers
▸▸ Introduction
I
n this chapter, Dr. Summers provides a scholarly review of the main theories that apply to
the ethics of healthcare situations. Why is knowledge of theory important to busy healthcare
professionals? In this time of great change and challenge within the healthcare system, there is
a need to apply ethics in all types of decision-making. To make this application successfully, one
needs a foundation in ethics, in addition to data and evidence-based management tools, including
those offered by advanced technologies. An understanding of ethics theory gives you the ability
to make and defend ethics-based decisions that support both fiscal responsibilities and patient-
centered care. While these kinds of decisions are difficult, without a foundation in ethics theory,
they might prove impossible. Therefore, this chapter and the one that follows, on the principles of
ethics, will serve as your ethics theory toolbox.
▸▸ Ethics and Health Care
From the earliest days of philosophy in ancient Greece, people have sought to apply reason in
determining the right course of action for a particular situation and in explaining why it is right.
Such discourse is the topic of normative ethics. In the 21st century, issues resulting from technological advances in medicine will provide challenges that will necessitate reasoning about the right
course of action. In addition, healthcare resource allocations will become more vexing as new diseases threaten, global climate change continues apace, and ever more people around the world find
their lives increasingly desperate. In the Patient Protection and Affordable Care Act of 2010 (ACA
2010) era, managers of healthcare organizations will find the resources to carry out their charge
increasingly constrained by multiple levels of change, differences in payment structures, and labor
shortages. A foundation in ethics theory and ethical decision-making tools can assist healthcare
leaders in assessing the choices that they must make in these vexing circumstances.
With the current emphasis on patient-centered care, knowledge of ethics can also be valuable when working with healthcare professionals, patients and their families, and policy makers.
In this sense, ethical understanding, particularly of alternative views, becomes a form of cultural
3
4
Chapter 1 Theory of Healthcare Ethics
competence.1 However, this chapter is limited
to a discussion of normative ethics and metaethics. Normative ethics is the study of what is
right and wrong; metaethics is the study of ethical concepts. Normative ethics examines ethics
theories and their application to various disciplines, such as health care. In health care, ethical concepts derived from normative theories,
such as autonomy, beneficence, justice, and
nonmaleficence, often guide decision-making.2
As one might suspect, when normative
ethics seeks to determine the moral views or
rules that are appropriate or correct and to
explain why they are correct, major disagreements in interpretation often result. These disagreements influence the application of views
in many areas of moral inquiry, including
health care, business, warfare, environmental
protection, sports, and engineering. FIGURE 1.1
lists the most common normative ethics theories to be considered in this chapter. Although
no single theory has generated consensus in the
ethics community, there is no cause for despair.
The best way to interpret these various
ethics theories, some of which overlap, is to
use the analogy of a toolbox.
Each of these theories provides tools that
can assist with decision-making. One advantage of the toolbox approach is that you will
not find it necessary to choose one ethics theory over another for all situations. You can
choose the best theory for a task, according to
the requirements of your role and the circumstances. Trained philosophers will find flaws
with this approach, but the practical advantages will suffice to overcome these critiques.
All of the theories presented have a value
in the toolbox, although like any tools, some
are more valuable than others. For example, I
can argue that virtue ethics has much value for
healthcare applications. Before explaining why
this chapter has chosen to present particular
theories, a quick overview is in order.
■■
■■
Authority-based theories can be faithbased, such as Christian, Muslim, Jewish, Hindu, or Buddhist ethics. They
can also be purely ideological, such as
those based on the writings of Karl Marx
(1818–1883) or on capitalism. Essentially,
authority-based theories determine the
right thing to do on the basis of what an
authority has said. In some cultures, the
authority is simply “that is what the elders
taught me” or “that is what we have always
done.” The job of the ethicist is to determine what that authority would decree for
the situation at hand.
Natural law theory, as considered here,
uses the tradition of St. Thomas Aquinas
(1224–1274) as the starting point of interpretation. The key idea behind natural
law is that nature has order both rationally and in accordance with God’s wisdom or providence. The right thing to do
is that which is in accord with the providentially ordered nature of the world.
In health care, natural law theories are
important because of the influence of the
Roman Catholic Church and the extent
to which the Church draws on Aquinas
as an early writer in the field of ethics.
Normative ethical
theories
Natural law
theories
Egoistic
theories
Authority-based
theories
FIGURE 1.1 Normative ethics theories.
Teleological
theories
Deontolgical
theories
Virtue
ethics
Ethical Relativism
■■
■■
■■
Several important debates, such as those
surrounding abortion, euthanasia, and
social justice, draw on concepts with roots
in natural law theory.
Teleological theories consider the ethics of
a decision to be dependent on the consequences of the action. Thus, these theories are called consequentialism. The basic
idea is to maximize the good of a situation. The originators of one such theory,
Jeremy Bentham (1748–1832) and John
Stuart Mill (1806–1873), called this maximization of good utility; thus, the name of
their theory is utilitarianism.
Deontological theories find their origins in
the work of Immanuel Kant (1724–1804).
The term deon is from Greek and means
“duty.” Thus, deontology could be called
the science of determining our duties.
Most authors place Kant in extreme opposition to consequentialism, because he
argued that the consequences themselves
are not relevant in determining what is
right. Thus, doing the right thing might
not always lead to an increase in the
good.3 More contemporary deontologists,
including John Rawls (1921–2007) and
Robert Nozick (1938–2002), reached antithetical conclusions about what our duties
might be.
Virtue ethics has the longest tenure among
all of these views, except for authoritybased theories. Its roots can be traced
to Plato (427–347 bce) and Aristotle
(384–322 bce). The key idea behind virtue ethics is to find the proper end for
humans and then to seek that end. In
this sense, people seek their perfection
or excellence. Virtue ethics comes into
play as people seek to live virtuous lives,
developing their potential for excellence
to the best of their abilities. Thus, virtue
ethics addresses issues any thinking person should consider, such as “What sort
of person should I be?” and “How should
we live together?” Virtue ethics can contribute to several of the other theories in
■■
5
a positive way, particularly in the understanding of professional ethics and in
the training necessary to produce ethical
professionals.
Egoistic theories argue that what is right
is that which maximizes a person’s self-
interest. Such theories are of considerable
interest in contemporary society because
of their relationship to capitalism. However, the ethical approach of all healthcare
professions is to put the interests of the
patient above the practitioner’s personal
interests. Even when patients are not
directly involved, such as with healthcare
managers, the role is a fiduciary relationship, meaning that patients can trust that
their interests come before those of the
practitioners. Egoistic theories are at odds
with the value systems of nearly all healthcare practitioners.
▸▸ Ethical Relativism
Before exploring any of these ethics theory
tools in depth, it is first necessary to confront
the relativist argument, which denies that ethics really means anything. Those who deal
with ethical issues, whether in everyday life or
in practice, will inevitably hear the phrase “It
is all relative.” Given that the purpose of this
text is to help healthcare professionals deal
with real-world ethical issues, it is important
to determine what this phrase means and what
the appropriate course of action is. Philosophers have not developed a satisfactory ethics
theory that covers every situation. In fact, they
are expert at finding flaws in any theory; thus,
no theory will be infallible. In addition, different cultures and different groups have varying
opinions about what is right and wrong and
how to behave in certain situations.4
Does the fact that people’s views differ mean that any view is acceptable? This
appears to be the meaning of such statements
as “It is all relative.” In that sense, deciding
that something is right or wrong, or good or
6
Chapter 1 Theory of Healthcare Ethics
bad, has no more significance than choices
of style or culinary preferences. Thus, ethical
decision-making and practice is a matter of
aesthetics or preferences, with no foundation
on which to ground it. This view makes a normative claim that there is no real right, wrong,
good, or bad.
One could equally say that there is no
truth in science, because scientists disagree
about the facts and can prove nothing, only
falsify it by experiment.5 However, the intrinsic
lack of final certainty in the empirical sciences
does not render them simply subjective. As
one commentator on the rapid changes in scientific knowledge put it, these changes reveal
“the extraordinary intellectual and imaginative yields that a self-critical, self-evaluating,
self-testing, experimental search for understanding can generate over time.”6 Why should
we expect any less of ethics?
Sometimes, there is a claim made that
because there are many perspectives, there cannot be a universal truth about ethics. Therefore,
we are essentially on our own. Hugh LaFollette
argued that the lack of an agreed-upon standard or the inability to generalize an ethics
theory does not render ethical reasoning valueless.7 Rather, the purpose of ethics theories is
to help people decide the right course of action
when faced with troubling decisions. Some
ethics theories work better in some situations
than in others. The theories themselves provide
standards, akin to grammar and spelling rules,
as to making decisions and supporting them
with a particular theory.
Thus, even though ethics might not produce the final answers, we still must make
decisions. Ethics theories and principles are
tools to help us in that necessary endeavor.
The lack of absoluteness in ethics theory also
does not eliminate rationality. Often, we simply must apply our rationality without knowing whether we are correct. The better our
understanding is of ethics, the more likely it is
that the decision we reach will be appropriate.
The ability to reach the appropriate decision is
especially important in the field of health care,
where our decisions affect the health, well-
being, and even the lives of our patients.
▸▸ Ethics Theories
Let us begin to examine the tools in the toolbox, not only knowing that we are fallible, but
also knowing that we are rational.8 The first
tool has little application to healthcare ethics;
however, it is widely believed and therefore
needs to be addressed. It involves the idea of
egoism in ethics.
Egoism
Egoism operates from the premise that people either should (a normative claim) seek to
advance solely their self-interests or (psychologically) this is actually what people do. The
normative version, ethical egoism, sets as its
goal the benefit, pleasure, or greatest good of
the self alone.9 In modern times, the writings
of Ayn Rand10 and her theory of objectivism11
have popularized the idea of ethical egoism.
For example, Rand said, “The pursuit of his
own rational self-interest and of his own happiness is the highest moral purpose of his
life.”12 This is a normative statement and a reasonable description of ethical egoism.
Although this theory has importance to
the larger study of ethics, it is less important
in healthcare ethics because the healing ethic
itself requires a sublimation of self-interests to
those of the patient. A healthcare professional
who fails to do this is essentially not a healthcare professional. No codes of ethics in the
healthcare professions declare the interests of
the person in the professional role to be superior to those of the patient.
Healthcare professionals who do not
understand the need to sublimate their own
interests to those of the patient or their role have
not yet become true healthcare professionals.
An understanding of the need to sublimate
one’s own interests for the sake of the patient
is essential in providing patient-centered care,
Ethics Theories
which has become a key emphasis in healthcare delivery.
Although occasionally healthcare professionals do not put the patient’s best interests
first, it is not a goal of the profession to put
one’s self ahead of the client or patient. A realist might complain, “Yet this is the way most
people behave!” Although that may be true,
the fact that many people engage in a particular kind of behavior does not make it into an
ethics theory. Ethical egoism constitutes more
of an ethical problem than anything else. Most
people who think of an ethics theory consider
it something that is binding on people. However, ethical egoism is not binding on anyone
else beyond self-interest. It is not binding on
all (i.e., normative) and, thus, does not meet
the criteria of a true ethics theory but is simply
a description of human behavior. Indeed, to
care for someone else above your self-interest,
as required by codes of ethics in health care,
is antithetical to the human behavior of truly
pursuing only your self-interest. Later, we shall
see how Rawls uses the idea that people pursue their self-interests to develop a theory of a
just society in which solidarity seems to be the
outcome, as opposed to the extreme individualism ethical egoism typically suggests.
Authority-Based Ethics Theories
Most teaching of ethics ignores religion-based
ethics theories, much to the chagrin of those
with deep religious convictions. A major problem with these theories is determining which
authority is the correct one. Authority-based
approaches, whether based on a religion, the
traditions or elders of a culture, or an ideology,
such as communism or capitalism, have flaws
relative to the criteria needed to qualify as a
normative ethics theory. Each of the authority-
based approaches, to be an ethics theory, must
claim to be normative relative to everyone. Because many of these authority-based
approaches conflict, there is no way to sort them
out other than by an appeal to reason. Not only
do we have the problem of sorting through the
7
ethical approaches, but also arguments inevitably arise concerning the religion itself and its
truth claims. If two religions both claim to be
inerrant, it is difficult to find a way to agree on
which of the opposing inerrant authorities is
correct.
In spite of the philosophical issues arising from the use of religion in healthcare ethics, it is important for healthcare providers to
understand the role of religions and spirituality in healthcare delivery. For example, all religions provide explanations of the cause or the
meaning of disease and suffering. Many theologies also encourage believers to take steps
to remove or ameliorate causes of disease and
suffering. Over the millennia, some of these
religions have even formalized their positions
by becoming involved with healthcare delivery
by providing inpatient and hospital care.
In addition, patients often have religious
views that help them understand and cope
with their conditions. Understanding a person’s faith can help the clinician and health
administrator provide health care that is more
patient-focused.13 For some patients, an ethical
issue may arise if their faith or lack of faith is
neither recognized nor respected. This failure
to address or respect the faith needs of patients
also conflicts with the tenets of patient-
centered care.
Beyond direct patient care, a second reason to understand the authority-based philosophies common in the healthcare environment
is their effect on healthcare policy. The role of
authority-based ethical positions appears to be
gaining importance in the 21st century. Effective working within the health policy arena,
whether at the institutional, local, regional,
state, federal, or international level, requires an
understanding of the influence of the religious
views of those involved in the debates and
negotiations. This knowledge can only serve
to strengthen your ability to reason with them.
In other words, it is important to understand
the “common” morality of those engaged in
the debate. The greater the diversity in beliefs
and reasoning, the more important the need
8
Chapter 1 Theory of Healthcare Ethics
for understanding what those beliefs and reasoning might be.
Religion also plays an important role in the
creation of healthcare policy, because religions
have provided a multiplicity of philosophical
answers to questions about the nature and
truth of the world. They also provide guidance
on that how we should act in the world. They
explain what is right or wrong and why it is
right or wrong. They also help people define
their identities, roles in the world, and relationships to one another. In addition, religions help
us understand the nature of the world and our
place in it.
Thus, as a tool, understanding authority-
based philosophical systems has value because
it can help in the treatment of patients. It also
increases your understanding regarding the
positions of persons who may be involved
in debates over healthcare issues, such as
resource allocations, or clinical issues such
as abortion. In addition, it is important to
understand authority-based philosophical
systems relative to yourself. As a healthcare
professional, your role requires that you do
not impose your religious views on patients.
At the same time, it is not part of the role for
you to accept the imposition of another’s religious values, even those of a patient.
These complex issues relate to professional
ethics and are not part of the scope of this chapter. However, it does seem incumbent on all
healthcare professionals to evaluate their own
faith and to recognize the extent to which they
might impose it on others. From the earliest
tradition of Hippocrates, the charge was to heal
the illness and the patient. More recently, the
Declaration of Geneva from the World Medical
Association stated that members of the medical
profession would agree to the following statement: “I will not permit considerations of age,
disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual
orientation, social standing or any other factor
to intervene between my duty and my patient.”14
In addition, patient-centered care requires that
healthcare professionals avoid judging patients
and treat them as individuals with a caring and
concerned manner. Let us now turn our attention to the oldest non-authority-based ethics
theory—virtue ethics.
Virtue Ethics
Virtue ethics traces its roots most especially to
Aristotle (384–322 bce). Aristotle sought to
explain the highest good for humans. Bringing the potential of that good to actualization
requires significant character development.
This concept of character development falls
into the area of virtue ethics because its goal is
the development of those virtues in the person
and the populace.
Aristotle’s ethics derived from both his
physics and his metaphysics. He viewed everything in existence as moving from potentiality to actuality. This is an organic view of
the world, in the sense that an acorn seeks to
become an oak tree. Thus, your full actuality is
potentially within you. As your highest good,
your potential actuality is already inherent
because it is part of your nature; it only needs
development, nurture, and perfecting. This
idea is still part of the common morality.
Finding Our Highest Good
Just what did Aristotle conclude was our final
cause or our highest good? The term Aristotle
uses for this is eudaimonia. The typical translation is “happiness.” However, this translation is
inadequate, and many scholars have suggested
enhancements. Many writers prefer to use the
translation “flourishing.” Because any organic
entity can flourish, such as a cactus, so the
term is not an adequate synonym.
The major complaint about translating
eudaimonia as “happiness” is that our modern
view of happiness would render it subjective.
No one can know whether you are happy or you
aren’t; you are the final arbiter. Aristotle thought
eudaimonia applied only to humans because
it required rationality that goes beyond mere
happiness. In addition, Aristotle’s eudaimonia
Ethics Theories
includes a strong moral component that is
lacking from our modern understanding of
happiness. In this sense, “happiness” would
necessarily include doing the right thing, that
is, being virtuous. Others could readily judge
whether you were living a virtuous or “happy”
life by observing your actions.
For Aristotle, happiness is not a disposition, as in “he is a happy sort.” Eudaimonia is
an activity. Indeed, children and other animals
unable to engage self-consciously in rational
and virtuous activities cannot yet be in the state
translated as Aristotle’s “happy.”15 Because it is
commonplace to describe children as being
“happy,” this is clearly not an adequate translation. Given these translation problems, I shall
use the term eudaimonia rather than its translations of “happiness” or “flourishing.” Essentially, you can understand eudaimonia best as
a perfection of character nurtured by engaging
in virtuous acts over a life of experience.
The most important element of eudaimonia
is the consideration of what it takes to be a person of good character. Such a person seeks to
develop excellence in himself or herself. Because
Aristotle recognized the essential social and
political nature of humans, developing individual excellence would also have to include consideration of how we should live together.
Developing a Professional as
a Person of Character
Consider what it takes to develop a competent
and ethical healthcare professional. The process involves a course of study at an accredited
university taught by persons with credentials
and experience in the field. It also includes
various field experiences, such as clerkships,
internships, and residencies or clinical experiences with patients. Part of the education
includes coming to an understanding of what
behaviors are appropriate for the role, which is
the definition of professional socialization.
For all healthcare professions, the educational process includes a substantial dose of
the healing ethic by specific instruction or by
9
observation of role models. The most fundamental idea behind this healing ethic teaches
healthcare professionals to sublimate their
self-interests to the needs of the patient. This
education also includes recognition of the
idea that the healing ethic means first doing
no harm and second that whatever actions are
done should provide a benefit.16
An Example of Professional
Socialization: The Character of
a Physician
The goal of professional education and socialization is to produce healthcare professionals
of high character. Many professional ethics
codes describe the character traits that define
high character, or what could be called virtues.17 For example, the 2016 American Medical Association statement of the principles
of medical ethics notes that the principles are
“standards of conduct which define the essentials of honorable behavior for the physician.”18
Essentially, the principles define the appropriate character traits or virtues for a physician.
Relative to virtue ethics, these traits or
virtues combine to create not only a good
physician but also a person of good character.
Like Aristotle’s person of virtue, engaging in
the activities of eudaimonia produces practical
wisdom. “Moral virtue comes about as a result
of habit.”19 The virtues come into being in us
because “we are adapted by nature to receive
them, and they are made perfect by habit.”20
Not only is practice required, but the moral
component is essential, too. Good physicians
are not merely technically competent; they are
persons of good character. How do we know
this? Their actions coalesce to reveal integrity
in all levels of their practice. In addition, a physician or any other person of good character
does not undertake to do what is right simply
to appear ethical. In a modern sense, the properly socialized physicians have internalized the
ethical expectations of their profession. To do
the right thing is part of their identities.21
10
Chapter 1 Theory of Healthcare Ethics
To use Aristotle’s term, physicians have
become persons of practical wisdom. In
describing practical wisdom, Aristotle says the
following:
■■
[I]t is thought to be the mark of a
man of practical wisdom to be able
to deliberate well about what is good
and expedient for himself, not in
some particular respect, e.g. about
what sorts of things conduce to
health or to strength, but about what
sorts of things conduce to the good
life in general.22
The mere fact that inculcation of such character traits is so important in all healthcare professions indicates that these ancient teachings
are part of the common morality, or at least the
professional morality of healthcare professions.
In short, persons of virtue nurture eudaimonia
because they believe it is the right way to live
and that “[w]ith the presence of practical wisdom [they] will be given all the virtues.”23 Good
physicians are living excellent lives; perfecting
themselves is part of their self-identities.24
These persons will act on the ethics principles
that form the core of their identification of
themselves with their role. In health care, these
principles function as virtues.
Principles of Biomedical Ethics
as Virtues
Beauchamp and Childress have popularized
what they call the principles of biomedical
ethics in a textbook of the same name that
has gone through seven editions from 1978 to
2013.25 The following list provides brief definitions of these principles:
■■
Autonomy is the ability to decide for oneself. The word derives from the Greek
words for “self ” (auto) and “rule” (nomos).
Autonomy means that people are free to
make their own decisions. The failure to
respect the personhood of others, making
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decisions for them without their consent,
is paternalism.
Beneficence is from the Latin root bene,
meaning “to do well.” More specifically,
it derives from the Latin word benefacere,
meaning “to do a kindness, provide a benefit.” It is the practice of doing the good
thing. Health care has clearly valued beneficence from its early Hippocratic origins.
It is the second part of the dictum “First do
no harm, benefit only.” As an active beneficence, professionalism requires healthcare practitioners to put patients’ interests
before their own. When combined with
beneficence, healthcare professionals hold
dear the virtue of altruism.
Nonmaleficence derives from the Latin
word mal, meaning “bad.” A malevolent person wishes ill of someone. Thus,
nonmaleficence means to not do wrong
toward another.
Justice is a concept with a vast history
and multiple interpretations. The etymology is Latin and suggests more than
just fairness. The words just and justice
include elements of righteousness (“She
is a just person.”), equity (“He received
his just due.”), and lawfulness (“She was
brought to justice.”).26 A just person is fair,
lawful, reasonable, correct, and honest.27
Most writers in ethics discuss two kinds
of justice, distributive and procedural.
Distributive justice determines the proper
sharing of property and of burdens and
benefits. Procedural justice determines
the proper application of the rules in the
hearing of a case.
These concepts are foundational principles of
healthcare ethics.28 A person having these virtues as part of his or her character structure,
self-definition, and actions is considered a
person of good character. In healthcare terms,
such a person would be walking the talk of the
healing ethic and would be a person of practical wisdom.
Ethics Theories
Elitism
A person who seeks to nurture eudaimonia
through his or her actions achieves this goal
after long practice of Aristotle’s practical wisdom. In applying practical wisdom, the person
has learned to live well, exemplifying what we
would call a person of virtue or integrity, a good
person. Such a person often sets the standard
for the right action in a particular situation.
Thus, virtue ethics has the problem of being
elitist. Owing to his view of the hierarchical
nature of reality, Aristotle thought that some
people were simply not capable of maximizing
their potential to reach the highest good.29
Aristotle noted the difficulty in encouraging many to a character of virtue, a life of
nobility and goodness.30 Aristotle believed that
living in fear, living by emotions, and pursuing
pleasures are the motivations for most people.
They lack even a conception of the noble and
truly pleasant, having never known it. Aristotle seemed to despair that once these bad
traits have long been in place, they are impossible to remove. He concluded, “We must be
content if, when all the influences by which
we are thought to be good are present, we get
some tincture of virtue.”31 The person of practical wisdom becomes the standard for ethical
decision-making. This leads to an understanding of how virtue ethics can facilitate the management of ethical conflicts.
Balancing Obligations from the
Virtue Ethics Perspective
Because different principles of ethics or different virtues conflict, it is not possible to practice
in the healthcare professions for long without
encountering some kind of ethical dilemma.
Some treatments involve harm (we are to do
no harm) yet provide a benefit (benefit only).
An experienced healthcare professional must
be able to explain the relative benefits and risks
of such treatments and gain the cooperation of
the patient for the treatments.
11
Sometimes, one principle alone might
create conflict. For example, physicians must
know how to tell the truth to patients. Even
though information can be regarded as therapy, information delivered at the wrong time
or in the wrong way can be devastating. Information not delivered at the right time or never
delivered at all could mean that the physician
is not being honest and is guilty of paternalism. Learning how to deal with these issues
effectively takes experience (practical wisdom)
and theoretical knowledge.
A major component of the patient–
clinician relationship is the patients’ trust that
their caregivers have their best interests at
heart and that they are competent. If patients
perceive caregivers as persons of integrity, virtue, or practical wisdom, their confidence in
their caregivers will increase. That increase in
patients’ confidence has documented effects
on enhancing the placebo effect.32 How caregivers communicate, and even how they carry
themselves, will do much to influence these
perceptions.33 A caregiver who knows how to
do these things is a person of practical wisdom,
at least when it comes to medical practice.
Caregivers with practical wisdom, which,
by necessity, includes being of good character,
or virtuous, will also be able to make appropriate decisions about the means to ends. This
has significant implications for healthcare
ethics. When faced with ethical challenges
in medical care, such caregivers will have the
practical wisdom to know how to weigh the
various issues and concerns and form a conclusion. Because wise and good people can,
and do, come to different conclusions about an
ethically appropriate choice of action, persons
of practical wisdom should consult with one
another.
Healthcare organizations have sought to
institutionalize this approach by using ethics committees. Those with practical wisdom
in health care are far ahead of most professionals in having a decades-long tradition of
ethics committees, ethics consultations, and
12
Chapter 1 Theory of Healthcare Ethics
institutional review boards. The key here is
that persons of good character, pursuing virtuous ends, are much more likely to make an
appropriate choice than those without such
experience or such character. These choices
would appear to refute one of the usual criticisms levied against virtue ethics—that there
is no clear way to resolve disputes when those
who have practical wisdom disagree about the
correct course of action. Mechanisms such
as ethics committees lead the deliberators to
make a decision, even though it may not be
unanimous.
Virtue ethics thus leads to the conclusion
that within health care at least, the probability is good that persons socialized to put the
patient’s interests first will come up with the
ethically correct ranking of options. They will
also respect the patient’s wishes, even if they
do not agree with those wishes.
Of course, this depiction makes the situation sound much better than it is. Persons
well trained in the healing ethic take unethical actions. Is that a fault of the education or
the person? Aristotle would fault the person.
In Aristotle’s view, some people, by nature, are
unable to control their passions, their desires,
and their emotions. Others are unable to act
rationally. Some are just wicked.34 Yes, the theory results in a form of elitism. However, it
seems fair to say that health care has a major
advantage over many other fields in that it has
a strong educational and socialization process for developing the right character. In a
sense, the purpose of the educational process
is to develop a cadre of elite professionals. In
doing so, they should become persons of high
character.
Ethics Theories and Professional
Roles
Knowledge of virtue ethics offers one further
advantage. Persons of practical wisdom should
be better prepared to know when to use a particular ethics theory, depending on the role
in which they find themselves. Again, take
physicians as an example. Although physicians
have a primary obligation to their patients,
it is not their only role. Consider the following physician roles, none of which involves
patients directly: conducting scientific studies;
negotiating with vendors selling equipment
and supplies; and hiring, firing, and supervising employees. In addition, physicians might
be negotiating with third-party payers, lobbying on behalf of health policy issues, and conducting peer reviews of other physicians. They
might also be involved in the management of
healthcare organizations and be part of various
advisory and regulatory agency boards. Many
other non-patient-related tasks could be listed,
such as working with community groups or
serving as faculty, as needed.
Some of the ethics theories work better in
certain roles than others. How do physicians
choose the appropriate theory? The socialization process seeks to develop caregivers
who are persons seeking the highest good, at
least in health care. This foundational process
should develop persons of integrity and practical wisdom who can manage the inevitable
ethical dilemmas and make the best ethical
decisions in any role. They can apply reason to
the situation and make the best-possible decision within their respective role.
Natural Law
The theory of natural law owes a great debt
to Aristotle. Natural law also is important
to Roman Catholic theology, given its origins with Aquinas. Many texts on ethics and
medical ethics leave out natural law or give it
short shrift. Some authors consider the theory
a version of moderate deontology,35 defining
deontology as simply any view that defines
the right thing to do as dependent on something other than consequences. Thus, there is
consequentialism and everything else. In the
realm of healthcare ethics, such an approach
appears overly limiting. As a tool in the ethics theory toolbox, there are a number of good
reasons to know natural law theory. Even if
Ethics Theories
philosophically one can reduce this theory to
another, natural law is sufficiently definitive
and important to consider on its own merits.36
One key to understanding natural law is its
assumption that nature is rational and orderly.
This theory goes back to the ancient Greeks,
who believed that the cosmos was essentially
unchanging in its order. Aristotle certainly
believed this.37 This is now a statement of
physics—a statement about the nature of the
world—rather than a statement about ethics.
Natural Law’s Relationship to
Aristotle, St. Thomas Aquinas,
and the Catholic Church
Aquinas’s beliefs gained prominence in the
Catholic Church at the Council of Trent
(1545–1563). In 1879, Pope Leo XIII declared
Thomism (Aquinas’s theology) to be eternally
valid.38 Nearly all writers recognize Aquinas as
setting the standard for natural law theory, just
as Aristotle serves as the standard-bearer for
virtue ethics.39 Aquinas developed his theory
in his work titled Summa Theologica, meaning “the highest theology.” Aquinas structured
the work in the form of a series of questions,
which he answered.40
The Thomistic conception of natural
law proceeds as follows: “All things subject to
Divine providence are ruled and measured by
the eternal law” (ST IaIIae 91, 2). “The rational creature is subject to Divine providence in
the most excellent way . . . . Wherefore it has a
share of the Eternal Reason, whereby it has a
natural inclination to its proper act and end:
and this participation of the eternal law in the
rational creature is called the natural law” (ST
IaIIae 91, 2). This establishes that natural law
is given by God and thus authoritative over all
humans. Not only can we know the law, but
also as rational and moral creatures, we can
violate it.
Recall Aristotle’s concept of practical wisdom; Aquinas used the same concept. In fact,
he called Aristotle “the philosopher” and cited
13
him as frequently as Scripture. One can find
the importance of practical reason, how it
works, its similarity to Aristotle’s conception
of it, and the most concise statement of what
the natural law compels in Aquinas’s writings.
The first principle of practical reason is
one founded on the notion of good, namely
that good is that which all things seek. Hence,
the first precept of law is that good is to be done
and pursued and evil is to be avoided. All other
precepts of the natural law are based upon this:
whatever the practical reason naturally apprehends as man’s good (or evil) belongs to the
precepts of the natural law as something to be
done or avoided (ST IaIIae 94, 2).
Unfortunately, some have stopped at this
quote and simply say that natural law means
to “do the good and avoid the evil.”41 Because
this lacks clarity about what the good might be
or about any decision rule by which to decide
what to do when goods conflict or when rankings are required, this statement alone does
not constitute an ethics theory. It sells the theory short.42
Aquinas also drew on Aristotle’s idea of
potentiality moving to actuality and states that
in the realm of what is good, “all desire their
own perfection” (ST Ia 5, 1). Again, following Aristotle’s lead, Aquinas noted that when
it comes to practical reason, the rules might
be clear but their application might not be. In
short, the details make the principle more difficult to apply (ST IaIIae 94, 4).
Aquinas then offered an excellent example that shows the difficulty at hand. Everyone
would agree that in general, “goods entrusted
to another should be restored to their owner”
(ST IaIIae 94, 4). However, Aquinas noted
that “it may happen in a particular case that
it would be injurious, and therefore unreasonable, to restore goods held in trust; for
instance, if they are claimed for the purpose of
fighting against one’s country. And this principle will be found to fail the more, according
as we descend further into detail” (ST IaIIae
94, 4). Taking this practical wisdom approach
even further, he generalized that “the greater
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Chapter 1 Theory of Healthcare Ethics
the number of conditions added, the greater
the number of ways in which the principle
may fail” (ST IaIIae 94, 4).
Aquinas even went so far as to note that
although all are governed by the natural law,
all might not know it or act upon it: “In some
the reason is perverted by passion, or evil
habit, or an evil disposition of nature” (ST
IaIIae 94, 4).43 So what are we to do? In seeking a principle to determine what is good and
what is bad, it is not difficult to find specific
behaviors listed by Aquinas. However, an
excellent philosophical overview of natural
law by Michael Murphy concluded that there
are no obvious master principles but only
examples of flawed acts.44 The Catholic Encyclopedia suggested a number of things that
would be wrong or right under the dictum
to always do good and avoid harm. However,
there was nothing about how to resolve conflicts among these requirements.45 This seems
to add a quandary. All decisions are specific,
and the details will change, so are there any
decision rules?
At this point, scholars disagree on exactly
how Aquinas resolved the quandary, and we
do not need to follow them in those debates.
However, there is still a need for a decision
principle when there are disputes regarding
which of the various actions to take. There are
two such principles, and the one most closely
associated with natural law theory is that of the
double effect.
Principle of Double Effect
The first principle that proposes to distinguish
between a good and an evil is the theory of double effect. Derived from Summa Theologica, the
principle has four key points:
■■
■■
■■
The act must be good, or at least morally
neutral, independent of its consequences.
The agent intends only the good effects,
not the bad effect.
The bad effect must not be a means to
the good effect. If the good effect were to
be the causal result of the bad effect, the
■■
agent would intend the bad effect in pursuit of the good effect.
The good effect must outweigh the bad
effect.46
The theory of double effect has use in medical ethics when dealing with abortion,
euthanasia, and other decisions where there
is a conflict between a good and an evil. For
example, under this view, abortion is an evil,
but saving the life of a mother is a good. Under
this view, euthanasia is an evil, but relieving
pain by the use of morphine is a good. If the
person dies and the death was not intended,
then is it acceptable? Major issues arise in the
application of the theory concerning how to
determine a person’s intent. We know that
not everyone is a person of practical wisdom
who only has a good intent. However, how
would we know the intent in a particular
case?47
At the policy-making level, is it acceptable to cut taxes for the rich at the expense
of the poor? What good comes of it? Because
there are few rich and many poor, does the
good of the rich count more than the good
lost by the poor? Note that the further we
delve into these types of questions, the more
important consequences seem to become,
until natural law becomes a form of consequentialism, perhaps rule consequentialism.48 It is not necessary to resolve these
disputes here, because the purpose is to
understand the theories for the purposes of
making appropriate decisions in health care.
Relative to that end, a second decision rule
for natural law is available.
Entitlement to Maximize Your
Potential
The key to understanding this proposed
decision rule relates to metaphysics: “Ethics
especially is impossible without metaphysics, since it is according to the metaphysical
view we take of the world that ethics shapes
itself.”49 The Thomistic ethic draws heavily on
the Aristotelian metaphysics that describes
Ethics Theories
the world as a hierarchy of being, with all entities in it striving to reach their own complete
state of actualization of their potential. This
means that it is part of the natural order for
all entities to strive to maximize their potential. To deny something its ability to actualize its potential is to violate its very nature.
Such a violation causes harm to the entity and
would be a violation of its nature and of the
natural law to avoid harm. Thus, natural law
proscribes any activities that would violate
an entity’s potential.50 Concerns about termination of potential, at least for rational creatures, are evident in several contemporary
healthcare issues.
Many religions and social activists place
considerable emphasis on social and political factors that prevent humans from actualizing their potential. These groups often are
at the forefront of social justice movements
addressing poverty, ignorance, unhealthy living conditions, and slave-like working conditions. Clearly, healthcare professionals need to
understand natural law theory when working
with patients who believe in its tenets and with
those who advocate social justice. This might
include those who are working to improve
public health, social conditions, or human
rights. Now let us look at another common
ethics theory, deontology.
Deontology
The derivation of deontology comes from the
Greek word deon, which means “duty.” Thus,
deontology is concerned with behaving ethically by meeting our duties. The ethics theory
of deontology originates with the German
philosopher Kant (1724–1804).51 Although
Kant’s influence on deontology is significant,
many other thinkers are part of the deontological tradition as well.52 Nonetheless, just as
we relied on Aristotle for virtue ethics and on
Aquinas for natural law, Kant sets the standard
for deontology. Following the review of Kant,
we shall examine some of the more contemporary advocates of deontological theories.
15
Kant’s Metaphysics and
Epistemology Grounded His
Ethics
Kant is most well-known for his work in metaphysics and epistemology, the Critique of Pure
Reason,53 but he also did groundbreaking work
in ethics. Kant’s writings on ethics appear in
several different volumes, with titles such as
Groundwork of the Metaphysics of Morals54 and
Critique of Practical Reason55 among others.
The concept of honoring commitments clearly did not start with Kant, but his
approach to the issue led to the identification
of his ethics theory with deontology. Kant’s
work in metaphysics and epistemology had
a significant influence on this approach and
his ethical views. As seen with Aristotle and
Aquinas, a complete understanding of ethics
often includes a view about the nature of the
world and how we know it—in other words,
the disciplines of metaphysics and epistemology. Kant concluded that the belief that perception represented the world was incorrect,
or at least incomplete. Instead, the structure
of consciousness processes sense data through
the means of categories of thought and two
forms of intuition, space and time.
Of these categories of thought, the one
that relates most directly to ethics is causality. All experiences are subject to causation,
which in Kant’s view undermines free will. In
the Newtonian world of his time, it was widely
believed that if you could completely know
the behavior of all the matter in existence, you
could predict the future behavior of anything
material. This did not pose a problem for most
people at this time because of the earlier dividing of mind and matter by Rene Descartes
(1595–1650). Like most people, Kant found
free will to be essential for ethics. If one’s every
act is determined, how can one be held responsible for one’s choices?
At the same time, Kant’s reasoning inexorably led him to conclude that we cannot
know what the world is like in and of itself.
It is beyond knowing, because we cannot
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Chapter 1 Theory of Healthcare Ethics
experience anything without use of the categories and forms of intuition. Kant, thus,
divided the realm of being into the phenomenal world of experience and the noumenal
world. We can think about the noumenal
world, but we cannot directly experience it.
Thus, we have “an unavoidable ignorance
of things in themselves and all that we can
theoretically know are mere appearances” (B
xxix).56 Relative to ethics, it should be clear
from Kant’s perspective that the metaphysical issue of whether free will is possible is
foundational.57
Kant argued that knowledge of the sensible world was insufficient for knowing the
moral law.58 Yet he also argued that free will
makes ethics possible. Free will is the precondition of ethics. If all things are determined
by natural causes, then our supposed ethical
choices are specious, an illusion. Humans, as
a natural phenomenon, are determined by natural laws; causality applies to all natural phenomena. However, the self, in and of itself (the
soul), is free from these laws.59
Kant recognized that this puts morality beyond the pale of empirical science, and
indeed, the question about free will is beyond
such testing. However, Kant believed that he
left a “crack in the door” that is wide enough
to allow for morality. He did this by arguing
that the concept of freedom, although not
knowable in a scientific way, is something
we can think about without contradiction:
“Morality does not, indeed, require that freedom should be understood, but only that it
should not contradict itself, and so should
at least allow of being thought” (B xxix).60 In
this sense, Kant redefined humans as participating in two kinds of reality, the phenomenal and the noumenal. According to Kant,
“There is no contradiction in supposing that
one and the same will is, in the appearance,
that is, in its visible acts, necessarily subject to the law of nature, and so far not free,
while yet, as belonging to a thing in itself, is
not subject to that law, and is therefore free”
(B xxviii).61
Freedom of the Will
Like Aristotle and Aquinas, Kant certainly
thought good character was laudable. However, he was concerned that the properties that
constitute good character, without a good will
to correct them, could lead to bad outcomes.
For example, we can misuse courage and perseverance without the direction of a good will.62
Kant went so far as to argue that one should
act on the duty of obligation to the moral law
regardless of any relationship that might have
an outcome such as eudaimonia: “A good will
is good not because of what it performs or
effects, not by its aptness for the attainment of
some proposed end, but simply by virtue of its
volition, that is, it is good in and of itself ” (AK
4:394).63 In other words, a good will is good
because it wills properly. Thus, Kant set a high
standard. Some of his language even suggests
that the true test of a good will is whether the
person continues to act out of duty and reverence for the moral law, even when doing so has
no personal benefit and might “involve many
a disappointment to the ends of inclination”
(AK 4:396).64
Reason, Autonomy, the Moral
Law, and the Will
Kant was distinctive relative to his predecessors in seeking to ground our duties in a
self-governing will. This is an appeal to reason
itself being autonomous, meaning that we are
free to choose. If we choose according to reason, we shall conform to the moral law: “If reason completely determined the will, the action
would without exception take place according to the rule” (AK 5:20).65 One can see the
extremely prominent principle of autonomy
coming into play here.
Typically, an autonomous agent is
one who makes his or her own rules and is
responsible for his or her actions.66 To violate
that autonomy is to violate a person’s innermost selfhood, something Kant developed as
one form of the categorical imperative. Thus,
Ethics Theories
one does not seek the foundation of ethics in
the development of a person of good character seeking to actualize his or her intrinsic
nature in order to seek the end of eudaimonia.
Instead, the subject matter of ethics is not
character but, rather, the nature and content
of the principles that determine a rational
will. Free will is determined by moral principles that cohere with the categorical imperative. This abstruse approach, for many, simply
disconnects the moral law and free will from
real life.
The idea of autonomy here is not the
view that individuals make their own laws.
It means that the laws that bind you in some
sense derive from your own making, your
own fundamental nature as a self.67 For Kant,
the will is free in the sense that you choose
to be bound by these principles of reason.
You freely choose to bind yourself to the constraints of the categorical imperative and the
dictates of reason.
The requirement of the duty to obey the
moral law to express a good will brings the
notion of intent into the discussion. Why a
person acts in such a way as to conform to
the moral law is an important component of
ethical evaluation in the Kantian scheme. Let
us turn to what Kant saw as rational principles that would ground ethics or the moral
law.
Kant attempted to discover the rational
principle that would ground all other ethical
judgments. He called this principle the categorical imperative. The categorical imperative is not so much a rule as a criterion for
determining what ethics principles meet the
test of reason.68 The imperative would have
to be categorical rather than hypothetical, or
conditional, because true morality should not
depend on individual likes and dislikes or on
abilities and opportunities. These are historical “accidents.” Any ultimate principle of ethics must transcend them in order to meet the
conditions of fairness. We shall later see how
Rawls used similar ideas in developing his
concept of a veil of ignorance. Kant developed
17
several formulations of the categorical imperative. The most commonly presented ones
follow:69
■■
■■
“Always act in such a way that you can also
will that the maxim of your action should
become a universal law” (AK 4:421).70
This principle often is caricatured as the
Golden Rule: Do unto others as you would
have them do unto you.71 This does not
capture the full meaning of what Kant had
in mind and may, indeed, miss the essence
of his teachings, as he specifically disavowed that this was his intended meaning (AK 4:430).72
“Act so that you treat humanity, both in
your own person and in that of another,
always as an end and never merely as a
means” (AK 4:429).73 Kant spoke of the
good society as a place that was a kingdom of ends (AK 4:433–434).74
The Categorical Imperative as a
Formal Decision Criterion
Although Kant believed that these two statements of the categorical imperative were formally equivalent, the first illustrates the need
to apply moral principles universally. That a
principle be logically consistent was important
to Kant. This principle of universal application
is also what allowed ethical egoism to be dismissed as something humans do when making
decisions but not as something that is an ethics theory. The second formulation points to
making the radical distinction between things
and persons and emphasizes the necessity of
respect for persons.
Kant’s theory evaluates morality by
examining the nature of actions and the
will of agents rather than goals achieved.
You have done the right thing when you act
out of your obligation to the moral law, not
simply because you act in accordance with
it. Note the fundamental importance of
intent as compared with any concern with
outcomes. One reason for the emphasis on
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Chapter 1 Theory of Healthcare Ethics
duties in Kant’s deontology is that we are
praised or blamed for actions within our
control, and that includes our willing, not
our achieving.
Kant did care about the outcomes of our
actions, but he thought that as far as the moral
evaluation of actions was concerned, consequences did not matter. As Kant pointed out,
this total removal of consequences “is strange
enough and has no parallel in the remainder of
practical knowledge” (AK 5:31).75 Let us now
look at the second version of the categorical
imperative, which is foundational in healthcare ethics.
The Categorical Imperative as
Respect for Persons
The second version of the categorical imperative emphasizes respect for persons. According
to Kant, you should “[s]o act as to treat humanity, whither in thine own person or in that of
any other, in every case as an end withal, never
as means only” (AK 4:429).76 People, unlike
things, ought never to be merely used. Their
value is never a means to our ends; they are
ends in themselves. Of course, a person might
be useful as a means, but you must always treat
that person with respect.
Kant held this view because of his belief
that people are rational and that this bestows
them with absolute worth: our “rational nature
exists as an end in itself ” (AK 4:428).77 This
makes people unique in the natural world. In
this sense, it is our duty to give every person
consideration, respect, and dignity. Individual
human rights are acknowledged and inviolable
in a deontological system. The major emphasis
on autonomy in health care springs from these
considerations and others like them. Although
most people who defend autonomy and treat
people as ends and not merely as means do
not use these formalistic Kantian reasons,
this principle of autonomy is foundational
in healthcare ethics. It is part of health care’s
common morality.
The Categorical Imperative and
the Golden Rule
According to the categorical imperative, if the
maxim or the rule governing an action is not
capable of being a universal law, then it is unacceptable. Note that universalizability is not the
same as universality. Kant’s point is not that
we would all agree on some rule. Instead, we
must logically be able to accept that it could
be universal. This is why the concept seems
very much like the Golden Rule.78 If you cannot will that everyone should follow the same
rule, your rule is not a moral one. As indicated
earlier, many think Kant’s first formulation of
the categorical imperative implies or even is a
restatement of the Golden Rule. However, Kant
specifically repudiates the Golden Rule interpretation (AK 4:430, note 13).79
Kant saw the justification for the Golden
Rule in terms of consequences and fairness. If
it is fair for me to do something, then it should
be fair for everyone. Alternatively, in consequential terms, we typically hear officials, merchants, managers, and parents, when they are
considering exceptions to policy, say, “If I do
X for you, I have to do X for everyone.” If one
made exceptions for each individual, then the
consequences would be unfair for others.80
Kant wanted to get beyond such issues.
He wanted to know whether a person performed an act out of duty to moral law and
thus expressed a good will. He stipulated that
the moral agent acting solely out of a good will
should ignore empirical considerations such as
consequences, fairness, inclinations, and preferences. For Kant, an act carried out from an
inclination, no matter how noble, is not an act
of morality (AK 4:398). Indeed, he went so far
as to say that the less we benefit from acting on
the moral law, the more sublime and dignified
it is (AK 4:425).81
Acts have moral worth if the person acts
solely from duty to the moral law, absent any
emotional inclinations or tangible benefits.
This sets up the difficult standard that we can
Ethics Theories
only know whether persons are morally worthy or obeying the moral law when there is
nothing in it for them. Their actions would be
opposed to their desires, inclinations, and even
their self-interests. Taking such an extreme
position essentially disconnected Kant from
the real world in which people live and make
ethical judgments.
Virtue Ethics and Kant’s Moral Law
Although likely controversial, it seems, for
purposes of healthcare ethics, that the best
way to make sense of Kant is to conceive of
the person of a good will in a manner akin to
Aristotle’s virtue ethics. Thus, to make Kantian
deontology useful, you could say that a person of a good will also is a person of practical
wisdom, as described by Aristotle. Does this
inclusion of Aristotle reject Kant’s work? No,
but a critical analysis and comparison to virtue
ethics are warranted.
Although Kant’s theory suffers from disconnection from any normal motivational
structure in human life, it still has applications
in healthcare ethics.82 The deontological theory emphasizes the attention to duty found in
all codes of ethics in health care. Kant put into
sharp relief the ethical idea that it is wrong for
people to claim they can follow a principle or
maxim that suits their interests but would not
want others to do the same. Most important
for health care is the recognition of human
dignity and autonomy. To use people solely as
a means to an end, whether as teaching material in medical schools, prisoners in research
experiments, or slaves, is fundamentally a violation of all beings.
Deontology poses two problems that lead
many to reject it. First, the statement of categorical imperatives, maxims, duties, rules, or
commandments yields only absolutes. Kant
really had only one absolute—you must act
solely on the basis of a good will. You must
have a reverence for, and an obligation to,
the moral law formalized by the categorical
19
imperative. However, the lack of prescriptive content leaves many unsatisfied. Actions
either pass or fail, with no allowance for a
“gray area.” Virtue ethics handles the gray
areas by depending on the wisdom of the person of practical wisdom. This is one reason
virtue ethics as an ethical tool enables us to
handle the problems of healthcare ethics more
robustly.
The inability to make distinctions between
lesser evils or greater goods is the other problem. We face moral dilemmas when duties
come into conflict and there is no mechanism
for resolving them. Kant, with his limited
description of only one ethical duty (to obey
the moral law), could claim to escape this
problem within his philosophy. He used the
radical view that such decisions are outside the
bounds of morality if based on inclinations or
consequences. Defining the real world of ethics
in this radical way does not help much when
faced with decisions that involve your inclinations and the weighing of consequences. Even
if you have, as Kant seemed to think, only one
duty, it is a formal one, and its various manifestations could conflict.
Virtue ethics and natural law theory face
this problem of conflicting duties as well. For
example, whereas abortion is clearly wrong
under natural law theory, the outcomes of
unwanted children, starving children, child
abuse, malnutrition, etc., also have a moral
bearing. Duties also conflict in healthcare situations. For example, if I tell the truth in some
situation, it may lead to someone getting hurt,
whereas a lie could have prevented it. However, my duty is both not to lie and not to do
things that cause harm to others. Therefore,
any decision violates a duty. Pure deontology
theory does not allow for a theoretically satisfying means to rank conflicting duties. However, most duty-driven people will not be so
literal with the Kantian version of deontology
that they are unable to rank conflicting duties.
Virtue ethics offers guidance for people using
practical wisdom with available tools such as
20
Chapter 1 Theory of Healthcare Ethics
considered judgments, common morality, ethics theories, and ethics principles.
Of the theories presented so far, virtue
ethics offers a much more useful and helpful
approach in achieving ethical processes and
ethical outcomes in the realm of health care.
Virtue ethics is more interested in the development of ethical persons than in the development of maxims and imperatives. The normal
understanding of the Golden Rule works perfectly well in ethical decision-making within
the framework of virtue ethics, even if Kant
himself disavowed it.
The policy implications for deontology
are significant because of the emphasis on duty
and the training of most healthcare professionals in the duties incumbent upon them. The
emphasis on duty leads most clinicians to consider themselves deontologists. However, most
would balk at the pure Kantian version of duty
and would more readily assent to the duties
experienced by a person of practical wisdom.
Duty-driven clinical staff can walk into a meeting and know in advance what the right thing
to do is: maximize the benefit to their patients.
This is their duty, and their professional code
of ethics codifies this duty. If they had to rank
their duties, it would be patients first, their
profession second, other clinical professionals
third, with maybe their employing organization a distant fourth.
Having such a clear sense of their duties
makes it easy for clinicians to talk about their
obligations to patient care. In contrast, healthcare administrators and officials who make
policy have a more difficult ethical chore. They
must balance competing claims among many
groups, and their loyalty is not simply to one
group. Administrators represent the organization, whereas clinicians represent individual
patients. The ethical obligations of administrators are much more complex; if the organization fails, the clinicians will not be able to
help the patients. Let us now look at two deontologists whose theories have a more practical
influence on the issues involved in healthcare
policy decisions. Their theories are important
because of the need to allocate burdens and
benefits such as access to health care that is of
high quality and that is not delivered in a way
that denies us other social goods because of its
high costs.
Non-Kantian Versions of
Deontology: John Rawls and
Robert Nozick
This section presents two influential and relatively recent theorists from the deontological
tradition. Rawls and Nozick have different
ideas of what is right. They argue that by following their principles of what is right, a more
just society will result. Of course, as philosophers do, they disagree over not only what is
right but also what is just. These two thinkers
have influenced the debate on the provision of
health care in our nation, including the recent
healthcare reforms.
John Rawls (1921–2002)
Rawls’s A Theory of Justice, published in 1971,
is considered a seminal text. Knowledge of his
ideas is part of the common morality of most
policy makers, even if many expressly reject
those ideas. The basic idea behind Rawls’s theory of justice is “justice as fairness.”83 Rawls
limits his plan to a theory of justice that would
apply to a society where the rule of law is
respected.84 People in such a society will differ with regard to their goals and their views of
what counts as just. Yet, they recognize agreedupon methods to arbitrate disputes so that they
are capable of continued functioning within
society. In other words, a disappointment or
a disagreement does not lead to violence or
rebellion. Rawls identified himself as being in
the tradition of social contract theorists and, as
a deontologist, even a Kantian. Rawls said that
his theory is essentially deontological because
it is not consequentialist.85
The idea of a social contract as the origin of society goes back to Thomas Hobbes
Ethics Theories
(1588–1679), John Locke (1632–1704),
David Hume (1711–1776), and Jean Jacques
Rousseau (1712–1778). All of these thinkers
conceived of the beginnings of civil society as
a compact or contract made among consenting adults to give up certain things in order to
achieve others, such as order, harmony, trade,
security, and protection. They agreed about the
idea of a hypothetical situation that could be
altered by persons acting to obtain some rights
and privileges in exchange for others without the use of coercion. Rawls used a similar
hypothetical situation and called it the original
position, in which rational people are behind
a veil of ignorance relative to their personal
circumstances. The decisions about the principles of a just society that they select when
they know nothing about their circumstances
are what Rawls described as the principles of a
just society.
Rawls emphasized that people seek to
protect and maximize their self-interests. He
argued that fundamental to that goal is liberty.
He further argued—his most controversial
point—that to have a just society requires an
infrastructure and a system of rights that protect the minority and those who have fared less
well in life’s “lottery” than others. The key to
his theory is the situation in which bargaining takes place about the nature of society and
includes what those who are bargaining know
about their society and themselves. Rawls
called this the original position.
The Original Position and the
Veil of Ignorance
In explaining the original position, Rawls
took as rational the ethical egoist’s position
that everyone would want to maximize his
or her personal self-interest. However, while
negotiating the most just society for yourself, you are asked to voluntarily draw a veil
of ignorance over yourself. This veil of ignorance is, from a personal perspective, absolute. You know nothing about yourself at all.
You do not know your station in life, your
21
preferences, your motivational structure, your
willingness to take risk, your age, your health,
your socioeconomics, your intelligence, your
demographics—nothing.86 In one fell swoop
you have lost all the reasons for protecting
your particular advantages or for hedging your
bets to protect you from your disadvantages.
You know you want to be in the best-possible
circumstances when the veil of ignorance is
lifted and you leave the original position.87 Not
knowing exactly what to protect, we are then
inexorably forced to the kind of considerations
that are common in medical ethics when treating patients about whom we lack information
of any useful sort.
It is not unusual in healthcare settings to
have patients who are in need of treatment but
are unable to communicate their wishes. We
know nothing of their families, their station in
life, etc. Often, we cannot find anyone to speak
for them, and they cannot speak for themselves. We have no clue about what they would
have wanted. Normal notions of informed
consent, durable power of attorney, and substituted judgment fall away as tools for us. We are
forced back onto the position of deciding what
to do for such persons on the basis of the idea of
what a rational person would want in such circumstances. This position is sometimes called
the best interests standard.88 We could say that
persons with such a complete inability to speak
for their own interests are in the original position. In this situation, this original position,
they are all truly equal because we know nothing of their circumstances.89
Now, although we are behind this veil of
ignorance relative to our personal circumstances, we nonetheless have a considerable
amount of knowledge about other things.
Rawls allowed those who are behind the veil
of ignorance to know general laws pertaining
to political affairs and economic theory and
to know something of human psychology.90
Indeed, he assumed that the parties will “possess all general information”91 but no information about their own particulars. Thus, they
have no way of calculating the probability that
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Chapter 1 Theory of Healthcare Ethics
they will be in a certain position as a result of
their choices. Only by such extreme means did
Rawls believe that one can ensure the fairness
of the result. It is a hypothetical thought experiment that, he argued, guarantees that whatever principles are chosen will be just.
In his view, everyone should get an equal
share of the burdens and benefits, unless there
is a material reason to discriminate. If our job
is to come up with a set of principles that will
decide what these material reasons are, then
we should carry out our job with the least bias.
If we go back to the ideal of justice as blind,
we see that the blindfold has become a veil of
ignorance. Rawls did not at all advocate that
we would seek an equalitarian outcome. He
assumed that we are persons who want to maximize our self-interests, but he did not assume
concepts such as benevolence or even nonmaleficence.92 Once we determine the principles of a just society, then we can use them to
develop material reasons to discriminate in the
distribution of burdens and benefits.
Two Basic Principles of Justice
The first principle of justice meets with little
objection, but the second inspires considerable
debate. Rawls ordered these principles serially,
in that liberties in the first principle cannot
be rationally traded for favorable inequalities
described in the second principle.93 The prioritizing of liberty above other principles of justice was how Rawls distinguished himself from
consequentialists. Their perspective, according to Rawls, is that there is only one principle:
the greatest good for the greatest number.94
Rawls described the first principle of justice
as follows: “[E]ach person is to have an equal
right to the most extensive basic liberty compatible with a similar liberty for others.”95 This type
of right is similar to the liberties protected in the
U.S. Bill of Rights and can be called a process
right. He described these rights as follows:96
■■
Political liberty (the right to vote and to be
eligible for public office)
■■
■■
■■
■■
Freedom from arbitrary arrest and seizure
(which goes back to habeas corpus)
Freedom of the person, along with the
right to hold (personal) property
Freedom of speech and assembly
Liberty of conscience and freedom of
thought
Rawls took a controversial position relative
to the distribution of inequalities of office,
income, wealth, and goods. He called this the
“difference” principle.97 In this second principle of justice, social and economic inequalities are appropriate if they are arranged such
that the inequalities actually help out the least
fortunate persons in society. In addition, the
inequalities should be connected to positions,
offices, or jobs in society that everyone has an
equal opportunity to attain.98 The inequalities
that Rawls saw as permissible are (i) inequalities in the distribution of income and wealth
and (ii) inequalities set up by institutions that
use differences in authority and responsibility
or chains of command. Rawls also said that
society cannot justify a decrease in liberty by
an increase in social and economic advantages.
In this sense, liberty is the most important of
the principles.
A classic example of how Rawls’s principles might apply relates to physicians. Physicians often command superior incomes and
social status, which are clearly inequalities.
This circumstance requires an explanation.
Once everybody is out of the original position
and back in the real world, the hope is that
anybody can become a doctor if he or she has
the talent.99 Suppose a person decides that he
or she wants to become a physician. However,
obtaining the education needed to actually
become a physician requires an inequality: less
fortunate people help pay for this education
with their taxes. In the just society envisioned
by Rawls, the person desiring the education
would have to compensate the less fortunate in
some way once he or she became a physician.
The physician is free to keep the wealth, or at
least some of it. But because gains in wealth are
Ethics Theories
allowed only if they benefit the least advantaged along the way, the physician would never
escape an obligation to help the less fortunate.
Some Concerns with Rawls’s
Theory
According to the difference principle, inequalities may be justified but only if they are to
the advantage of the least well off. Rawls considered it “common sense” that all parties be
happy with such a principle.100 Rawls also
stated that “the combination of mutual disinterest and the veil of ignorance achieves the
same purpose as benevolence.”101 However, it is
not difficult to imagine that many would voice
concerns over forced beneficence and the government mechanisms and taxing schemes that
would be needed to identify what counts as a
natural gift or talent and is therefore unearned.
Consider the relatively bitter discussion
of reparations to the descendants of slaves.102
Recall the still active debates over affirmative
action or over how to treat illegal immigrants
or their American-citizen children. Many if
not most of the wealthy would also be unlikely
to assent to the thought experiment of putting
on a veil of ignorance, because they would not
accept the forced benevolence that the difference principle imposes. Simply put, many are
less interested in justice than in keeping their
advantages for themselves and their children.
Thus, Rawls’s position, although just, runs into
human nature.
Some might argue that because Rawls was
running up against human nature, his theory
should be dismissed. Rawls addressed such
arguments. He was perfectly aware of the imperfections of the real world outside the veil of
ignorance; that is why he invented the thought
experiment. The fact that the distribution of
burdens and benefits by nature is unequal is
not an excuse. “Occasionally this reflection is
offered as an excuse for ignoring injustice, as if
the refusal to acquiesce in injustice is on a par
with being unable to accept death.”103 Rawls
23
believed that “the natural distribution is neither
just nor unjust.”104 As Rawls stated, “[T]hese are
simply natural facts. What is just and unjust is
the way that institutions deal with these facts.”105
Thus, it is up to us to decide the principles of
a just society and to take steps to create that
society.
Rawls conceded that one might affirm his
or her contract approach but eschew the difference principle, or vice versa.106 To understand Rawls’s theory and its application, we
need to examine his most famous opponent,
Nozick, the philosophical defender of libertarianism. Nozick accepted neither the contract
approach of the original position nor the difference principle.
Robert Nozick (1938–2002) and
Libertarianism
Nozick and Rawls both worked in the Department of Philosophy at Harvard University at
the same time, but their philosophies disagreed considerably. However, both described
themselves as coming from the deontological
tradition relative to ethics theory in that they
rejected consequentialism. Nozick’s first, and
most famous book, Anarchy, State, and Utopia (1974), was an attack on Rawls’s work that
focused on the extensive state envisioned as
necessary to bring about Rawls’s ends.107
In the healthcare field, Nozick’s work in
political theory helps provide the theoretical
underpinnings to the debate that argued that
there are no positive rights to health care, nor
should there be any.108 On the other side, Rawls’s
difference principle can be used to argue for
health care as a component of the primary social
goods.109 Thus, Rawls and his followers represent the liberal tradition that the government
should step in to help people disadvantaged
in life’s lottery, while Nozick and his followers
represent the conservative tradition that if you
want something you should obtain it yourself.
Like Rawls, Nozick claimed roots in
Kant. However, Nozick focused on the second
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Chapter 1 Theory of Healthcare Ethics
formulation of the categorical imperative. You
may recall that Kant said, “So act as to treat
humanity, whither in thine own person or
in that of any other, in every case as an end
withal, never as means only” (AK 4:429).110
Nozick drew on this formulation, earlier
described as the emphasis on autonomy. In
the first sentence of the book, he stated his
approach clearly: “Individuals have rights,
and there are things no person or group may
do to them (without violating their rights).”111
He said that this imperative puts a constraint
upon how others may be used. He stated that
this version of autonomy can “express the inviolability of others.”112
Nozick argued that Kant, in his categorical
imperative, did not simply say we should minimize the use of humanity as a means. Rather,
he said we should treat others as ends in every
case, never as means only.113 The word “only”
leaves the meaning of this statement open to
alternate interpretations that would suggest
that minimization is all anyone could really
mean in the actual world. In Nozick’s view,
people obviously are means to ends. If people
are means to ends, then how is it possible to
treat them only as ends?
Nozick also said that if we take his view of
Kant and the inviolability of persons seriously,
then we misspeak when we say that someone
must make a sacrifice for the social good. He
argued that there is no social entity to whom
we can make a sacrifice; there are only other
persons. Social entities are simply abstractions.
“Using one of these people for the benefit of
others uses him and benefits others. Nothing
more . . . Talk of an overall social good covers
this up.”114 To use a person in this way is to fail
to respect him or her as a separate person: “No
one is entitled to force this [sacrifice] upon
him—least of all a state or government.”115
Nozick also objected to Rawls’s difference principle. He opposed the forced redistribution of benefits and burdens so that the
less fortunate are made better off as the price
for the more fortunate being more fortunate:
Holdings to which people are entitled may not
be seized, even to provide equality of opportunity for others. In the absence of magic
wands, the remaining means toward equality
of opportunity is to convince each person to
choose to devote some of his or her holdings
to achieving it.116
Simply put, if you do not like what you
have, take steps to get more. If you want people
to help others, convince them to do it. Is this
justice? Are we really being just if we tell people who are severely disadvantaged to choose
to improve themselves?
Rawls would hold that such outcomes are
arbitrary—not just—in that they are based
on the natural lottery, over which we have no
control. The veil of ignorance is intended to
get us to think about the principles of justice
that would follow if we did not know our personal circumstances. For Rawls, what is just is
what persons in that original position would
choose.117 The principles that result are the
distributive justice principles of a just society.
Nozick claimed that theories like Rawls’s could
be defeated by voluntary agreements. Indeed,
he opposed the use of the term “distributive
justice” because it implied a central distribution authority. This is not the reality of free
adults, so he preferred the term “holdings”
and talked of how they are acquired and transferred.118 Nonetheless, he was unable to escape
completely from the long tradition of the term
“distributive justice” and continued to use it.
He specified three conditions that meet the
requirements of distributive justice:119
■■
■■
■■
“A person who acquires a holding in
accordance with the principle of justice in
acquisition is entitled to that holding.”120
If a person is entitled to the holding and
transfers the holding, the person to whom
it is transferred is now entitled to it.
No one is entitled to anything except
by gaining a holding from a previously
unheld state (principle 1) or obtaining it
from such a person by voluntary transfer.
An interesting outcome of Nozick’s reliance on
these three principles is that it is unnecessary
Ethics Theories
to argue that anyone deserves the outcome
that results.121 Nozick, thus, rejected the basic
idea of distributive justice; the principle is that
everyone should get an equal share unless
there is a material reason to discriminate. He
complained that any reason to discriminate
results in an inappropriate end state or patterned outcome.122 What was appropriate was
the three principles that he enunciated relative
to historical entitlement and then subsequent
transfers of holdings.
Most puzzling, at the end of his chapter
on distributive justice, Nozick did take up
what should be done to rectify the problems
of historical injustice. Justice prevails only in
following the three principles that described
proper acquisition and transfer. If these are followed, there is no injustice in the resultant outcomes, whatever they are. “If, however, these
principles are violated, the principle of rectification comes into play.”123 He then allowed
that a specified (he used the term “patterned”)
outcome might be appropriate to rectify the
past injustice. Nozick provided the following
view of how this could be done: “A rough rule
of thumb for rectifying injustices might seem
to be the following: organize society so as to
maximize the position of whatever groups end
up least well-off in the society.”124
This remarkable statement by the champion of libertarians sounded very like the difference principle.125 However, it left out Rawls’s
idea that the better off can be better off but only
if the less well off benefit as well. In Nozick’s
formulation, it seems we have moved back
to equalitarianism because our only interest,
when tasked to correct injustice, is maximizing the position of the least well off. The only
possible outcome of this logic must be a leveling or rising of everyone to the average.
Because what happened historically is
what counts as justice, it would be hard to find
a significant case in which the original holdings
were justly gained. For example, when Thomas
Jefferson made the Louisiana Purchase, it was
certainly a great surprise to the Native Americans, who had been living there for thousands
25
of years, that they had no ownership rights in
their land. This loss of ownership rights ended
up being true for them no matter how much
labor they had mixed in with the land.126
As a libertarian, Nozick’s principles resonate loudly with those who emphasize the free
market and a meritocracy. Typically, these will
be the same people who resist calls for allocation of resources to healthcare needs, especially if this is done by taxation.
The extent to which these libertarian
views are part of the common morality has a
great influence on healthcare policy.
At this point we have examined all but one
of the major ethics theories. Let us now examine the ethics theory that describes how most
administrators work: consequentialism.127
Consequentialism
Consequentialist moral theories evaluate the
morality of actions in terms of progress toward
a goal or end. The consequences of the action
are what matter, not their intent. This is in
contrast to previously noted theories (e.g.,
deontology, virtue ethics, and natural law) that
consider intent. Consequentialism is sometimes called teleology, using the Greek term
telos, which refers to “ends.” Thus, one finds
that the goal of consequentialism is often stated
as the greatest good for the greatest number.
Consequentialism has several versions, the
best known of which is utilitarianism. Utilitarianism defines morality in terms of the
maximization of the net utility expected for all
parties affected by a decision or action. For the
purposes of discussion, consequentialism and
utilitarianism are used here as synonyms.
For the consequentialist, the person’s
intentions are irrelevant to the ethical evaluation of whether the deed is right or wrong.
Outcomes are all that matter. The consequentialist will agree that intentions do matter, but
only to the evaluation of a person’s character,
not to the evaluation of the morality of his or
her acts. In natural law, virtue ethics, and deontology, part of the ethical assessment concerns
26
Chapter 1 Theory of Healthcare Ethics
the person’s intention. The consequentialist
would say that intention simply confuses two
issues: (i) whether the act itself is leading to
good or bad outcomes and (ii) whether the
person carrying out the act should be praised
for it or not praised. Consequentialists consider the second issue to be independent of
moral consideration relative to the act. It is
relevant only to the evaluation of the person’s
moral character. Of course, to leave out intentions completely seems to violate a deep sense
of our understanding about what it means to
be ethical. Most people find something wrong
with saying an act is ethical if it happened by
accident.
patient-centered care and meeting organizational needs. Consequentialism is often used as
a basis for decision-making. For example, one
could readily see that the creation of a diversity policy is justified by rule consequentialism.
Lawmakers and administrators who develop
health policies at the national level also use consequential arguments to justify decisions, such
as requirements to provide indigent care or
emergency services. To better understand the
use of consequentialism, we first must examine classical utilitarianism and consider rule
utilitarianism.
Types of Consequentialism
Classical utilitarians spoke of maximization of
pleasure or happiness. Classical utilitarianism
is most often associated with the British philosopher Mill (1806–1873). He developed the
theory from a pleasure-maximizing version
put forward by his mentor Bentham (1748–
1832). As clearly stated by Mill, the basic principle of utilitarianism is that actions are right
to the degree that they tend to promote the
greatest good for the greatest number.130
Of course, it is unclear what constitutes
“the greatest good.” For Bentham, it was simply
the tendency to augment or diminish happiness or pleasure. Bentham, being a hedonist in
theory, did not try to make distinctions about
whether one form of pleasure or happiness was
better than another.
For Mill, not all pleasures were equally
worthy. He defined “the good” in terms of
well-being and distinguished, both quantitatively and qualitatively, between various forms
of pleasure.131 Mill is closer to the virtue theory
idea of eudaimonia as a goal in that he specified qualitative distinctions rather than simply
adding up units of happiness or pleasure.132
Indeed, Mill said that one is duty-bound to
perform some acts, even if they do not maximize utility.133
A defining characteristic of any type of
consequentialism is that the evaluation of
whether an outcome is good or bad should
The two major types of consequentialism are
as follows:128
■■
■■
Classical utilitarianism (or act consequentialism). Each act is considered on the basis
of its net benefit. This version of utilitarianism has received the most criticism and is
not supported by modern ethicists. Nonetheless, it makes a convenient target for
those who dislike consequentialism. For
example, determining the consequences
of something is often an exceedingly data-
intensive undertaking, and the data may
be lacking. The facts regarding the consequences are also themselves in debate.
Imagine the difficulty if an administrator
had to make decisions on the basis of the
consequences of each employee’s actions
rather than a standard or rule.
Rule consequentialism. The decision maker
develops rules that will have the greatest
net benefit.129 The development of rules to
guide conduct is similar to the actions of
administrators who develop policies. This
rule version of consequentialism includes
two subspecies, negative consequentialism and preference consequentialism.
In organizational healthcare settings, policy-
making is an important component of providing
Classical Utilitarianism
Ethics Theories
be, in some sense, measurable, or that the outcome should be within the realm of predictability. Thus, in the realm of consequentialism,
ethics theory attempts to become objective,
seeking a foundation that is akin to the sciences. This principle is enshrined in the world
of commerce, trade, management, and administration as the cost–benefit analysis approach.
As a theory, consequentialism is not as
closely tied to its founder as are the previous
three theories discussed. Thus, rather than
probing the depths of Mill’s writing, a more
free-ranging approach is used, and the section
presents various versions of consequentialism
that are in play today. This approach will avoid
the considerable controversies surrounding
what Mill meant by his theories.134 It presents
tools derived from consequentialism tools that
are useful to persons dealing with issues in
healthcare ethics.
Relative to what consequentialism means,
Bentham insisted that “the greatest number”
included all who were affected by the action
in question, with “each to count as one, and
no one as more than one.”135 Likewise, in Bentham’s version of the theory, the various intrinsic goods that counted as utility would have an
equal value, such that one unit of happiness for
you is not worth more than one unit of happiness for me. Quite clearly, to talk about “units
of happiness” is far-fetched, and indeed, that is
one of the criticisms of the theory.136 However,
numerous correctives to the theory have been
advanced over the years, and some of these are
helpful.
Unlike deontology and natural law with
their conflicting absolutes, consequentialism
of any form allows for degrees of right and
wrong. If the consequences can be predicted
and their utility calculated, then in such situations, the choice between actions is clearcut: always choose those actions that have the
greatest utility. For this reason, the theory has
had great appeal in economic and business circles. However, in healthcare decision-making,
the economic view of utility is not fully satisfactory. For example, how do you compute
27
the suffering of someone whose spouse has
become disabled? Although attorneys do calculate the monetary value of life years lost
when there is an injury, whether monetary settlements can really compensate for a lost livelihood or a broken future is debatable.
In spite of this objection, administrators
of healthcare organizations, including managers, must often think in terms of the aggregate when evaluating their decisions. Persons
taking the tack of a deontologist and trying
to fulfill their duty can readily say that their
obligation is to the patient. Administrators
have to consider patients in the aggregate, the
organization, the larger community, and their
employees in their decision-making. Their
divided duties and obligations are part of
their job descriptions, as opposed to the single
obligation to the patient that clinicians enjoy.
Administrators also are trained to consider
their decisions in terms of maximization—the
best outcome for the resources expended is the
greatest good.137 They would say that utilitarianism assists them in obtaining the “biggest
bang for the buck.” Of course, in administration, as in ethics, problems arise:
■■
■■
■■
It is not always clear what the outcome of
an action will be, nor is it always possible
to determine those affected by it.
The calculation required to determine the
right decision is both complicated and
time-consuming.
Because the greatest good for the greatest
number is described in aggregate terms,
the good might be achieved under conditions that are harmful to some so long
as that harm is balanced by a greater
good. This leads to the attack that consequentialism means “the end justifies the
means.”138
The theory fails to acknowledge that individual rights could be violated for the sake of the
greatest good, which is sometimes called the
“tyranny of the majority.” Indeed, the murder of an innocent person would seem to be
condoned if it served the greater number. The
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Chapter 1 Theory of Healthcare Ethics
complaint is that consequentialism ignores the
existence of basic rights and ethics principles
such as autonomy and beneficence. The fact
that Mill would categorically deny this by saying some acts are wrong regardless of the consequences appears to be a violation of his own
stated philosophy. Of course, we are not seeking doctrinal purity but useful tools to help us
in healthcare ethics.
Finally, who has the time to run endless
computations every time a decision is needed?
“Analysis paralysis” would be the predicted outcome, which would not maximize any version
of utility. In any case, because of these problems, few philosophers today subscribe to act
consequentialism.139 The proposed improvement to several of these problems is rule
consequentialism.
Rule Consequentialism
The idea behind rule consequentialism is that
one evaluates behavior by rules that would
lead to the greatest good for the greatest number. At this point, the theory begins to tie in
more clearly to virtue ethics and to the person
who has achieved practical wisdom. It takes
a person of some experience to know how to
develop rules that will likely lead to the greatest good for the greatest number. Healthcare
administrators and government officials would
call these rules policies.
Once there is a policy, presumably developed by an evaluation of its likely outcomes,
then the person who needs to make a decision
refers to the applicable policy. Indeed, a person
of practical wisdom might well conclude that
long-term utility is undermined by acts of injustice. He or she would then develop a policy that
recognizes and respects autonomy. Rule utilitarianism would thus use the utility principle
to justify rules establishing human rights and
the universal prohibition of certain harms. Such
rules would codify the wisdom of experience
and preclude the need for constant calculation.
Thus, rule consequentialism looks like the
same activity in which healthcare administrators
and policy makers engage when they make policies and procedures. A policy is a general statement meant to cover any number of situations.
The person creating it makes the decision that
following the policy is the best way to achieve
the organization’s goals. The person then uses
procedures as the means to carry out the created policies. Healthcare administrators and
government officials have been using this process for a long time. Overall, it works well, even
though rules or policies do not work fairly in
every situation.
Indeed, the failure of the rules to fit every
situation is one of the reasons to have humans
in charge instead of machines. At this point,
the inclusion of a person of practical wisdom,
from the virtue ethics tradition, comes into
play. Administrators or clinicians (persons
of practical wisdom) can decide whether the
special circumstances warrant making an
exception to the rule when they need to make
judgments. If so, they could modify the rule
to consider the special circumstances. In …
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